Provider Demographics
NPI:1073120762
Name:ELIZONDO, MAYRA (FNP-C)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:ELIZONDO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2130
Mailing Address - Country:US
Mailing Address - Phone:903-595-5486
Mailing Address - Fax:903-595-5128
Practice Address - Street 1:1133 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2130
Practice Address - Country:US
Practice Address - Phone:903-595-5486
Practice Address - Fax:903-595-5128
Is Sole Proprietor?:No
Enumeration Date:2020-09-26
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX944960163W00000X
TXAP1097801363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX944960OtherRN